Which patient should not be prescribed alendronate (Fosamax) for osteoporosis?
A. A female patient being treated for high blood pressure with an ACE inhibitor.
B. A patient who is allergic to iodine/shellfish.
C. A patient on a calorie restricted diet.
D. A patient on bed rest who must maintain a supine position.
Correct Answer: D. A patient on bed rest who must maintain a supine position.
Alendronate can cause significant gastrointestinal side effects, such as esophageal irritation, so it should not be taken if a patient must stay in supine position. It should be taken upon rising in the morning with 8 ounces of water on an empty stomach to increase absorption. The patient should not eat or drink for 30 minutes after administration and should not lie down.
Option A: Contraindications to alendronate include patients with known hypersensitivity, esophageal abnormalities, delayed esophageal emptying, or achalasia. Severe risk of esophageal morbidity indicates avoidance in patients who are unable to sit or stand upright for at least 30 minutes. Avoid alendronate in patients with hypocalcemia.
Option B: ACE inhibitors are not contraindicated with alendronate and there is no iodine allergy relationship. Baseline concentrations of calcium and bone mineral density should be established before therapy begins, with follow-up testing at 6 to 12 months post-therapy. Calcium at baseline and continual monitoring is needed if hypocalcemia risk is recurring.
Option C: There is no restriction for alendronate on a patient taking a calorie restricted diet. The accumulation of alendronate in the kidney allows for persistent anti-fracture benefits even after cessation of treatment. Current recommendations suggest tailoring the drug holiday length to the individual patients. The average drug-holiday in low-risk patients is 3 to 5 years.